Patterns and predictors of mortality in a semi-urban population-based cohort in Sri Lanka: findings from the Ragama Health Study.

OBJECTIVE: To describe patterns and predictors of mortality in a semi-urban population in Sri Lanka. DESIGN: A prospective population-based cohort study. SETTING: Ragama Medical Officer of Health area in the Gampaha district, Sri Lanka. PARTICIPANTS: Adults between 35 and 64 years of age were recruited using an age stratified random sampling technique in 2007. MEASURES: At baseline, we recorded socio-demographic, lifestyle, anthropometric, biochemical and clinical data of the participants. Over 10 years, we obtained the cause and date of death from the death registration documents of deceased participants. We determined the survival probability of the cohort over 10 years and estimated Hazard ratios (HRs) for all-cause mortality (ACM), cardiovascular mortality (CVM) and cancer-related mortality (CRM) using Cox's proportional hazards model. We also estimated the survival probabilities for men and women in each 10-year age group and standardised mortality ratio relative to the source population. RESULTS: There were 169 deaths over 10 years with standardised mortality rates of 5.3 and 2.4 per 1000 years of follow-up for men and women, respectively. Independent predictors of: ACM were older age, lower income, smoking and diabetes mellitus while gender, education, occupation, harmful alcohol use, waist circumference and hypertension were not; CVM were older age, lower income, smoking, diabetes and hypertension while gender and harmful alcohol use were not; CRM was older age while gender, smoking and diabetes were not. Those engaged in clerical and technical occupations or unemployed had a lower risk of CRM as compared with those engaged in elementary occupations. CONCLUSIONS: Older age, lower income, smoking, diabetes and hypertension strongly predict mortality in this cohort. Addressing the identified modifiable predictors through behavioural modification will improve longevity in similar populations.

Usefulness of Routine Terminal Ileoscopy and Biopsy during Colonoscopy in a Tropical Setting: A Retrospective Record-Based Study.

Introduction. Available evidence for routine terminal ileoscopy during colonoscopy is equivocal. We investigated the place of routine terminal ileoscopy and biopsy during colonoscopy, in a tropical setting. Materials and Methods. All consenting adults undergoing colonoscopy had routine TI and biopsy. Patients with right iliac fossa (RIF) pain, diarrhoea, anaemia, suspected inflammatory bowel disease (IBD), and raised inflammatory markers were defined as Group A and all others undergoing colonoscopy as Group B. Results. Caecal intubation and TI were achieved in 988/1096 (90.15%) and 832/1096 (75.9%) cases, respectively. 764/832(91.8%) patients were included in final analysis. 81/764 (10.6%) patients had either macroscopic (34/81) or microscopic (47/81) abnormalities of terminal ileum; 20/81 had both. These were CD (28/47), tuberculosis (TB) (6/47), ileitis due to resolving infection (8/47), and drug-induced ileitis (5/47). 27/81 with macroscopically normal ileum had CD (18/27), ileitis due to resolving infection (5/27) and drug-induced ileitis (4/27) on histology. 12/764 (1.57%) patients with macroscopically normal colon had ileal CD (8/12), drug-induced ileitis (2/12), and resolving ileal infection (2/12) on histology. 47/764 (6.15%) patients had ileal pathology that influenced subsequent management. These were significantly higher in Group A (43/555 (8%)) than in Group B (4/209 (1.9%)) (P = 0.0048, χ (2) = 7.968). Conclusion. TI and biopsy improve diagnostic yield of colonoscopy in patients with RIF pain, diarrhoea, anaemia, suspected IBD, and raised inflammatory markers.

The long-term outcomes of a cohort of Sri Lankan patients with ulcerative colitis: a retrospective study at two national referral centers and review of literature.

BACKGROUND: Inflammatory bowel disease, especially ulcerative colitis, is increasing in many "non-Western" countries, including Sri Lanka. The aim was to evaluate long-term outcomes of ulcerative colitis in a Sri Lankan population. METHODS: A retrospective cohort study was conducted at the gastroenterology clinics of the Colombo North Teaching Hospital, Ragama and the National Hospital of Sri Lanka, Colombo; the two major referral centers for ulcerative colitis. All cases had histological confirmation of ulcerative colitis. Three outcomes: colectomy, development of colorectal carcinoma, and death were assessed. Patients not attending the clinic during the previous 4 weeks, or their families, were contacted to obtain clinical details and survival status. In those who had died, the cause of death was confirmed from clinical records and death certificates. RESULTS: Details of 348/425 (81.9%) patients with ulcerative colitis (mean age 45.6 [standard deviation {SD} 14.3] years, male/female ratio = 1.00:1.03) were available. The mean follow-up was 6.8 (SD 6.5) years. The cumulative colectomy rates at 1, 5, 10, and 15 years were 1.5%, 4.0%, 5.5%, and 9.3% respectively. The cumulative probability of colorectal cancer in this cohort after 10 and 15 years was 0.47% and 2.36% respectively. The cumulative survival rate after 1, 5, 10, and 15 years was 99.7%, 98.9%, 98.1%, and 94.5% respectively. Patients with pancolitis were more likely to have disease-related death (P = 0.05). Multivariate analysis (Cox proportional hazards model) showed that an older age at diagnosis was associated with long-term mortality (hazard ratio, 1.11; P = 0.001). CONCLUSION: In this cohort, colectomy, colorectal carcinoma, and death rates were low, suggesting a relatively benign disease course for ulcerative colitis.

Survival of patients with alcoholic and cryptogenic cirrhosis without liver transplantation: a single center retrospective study.

BACKGROUND: There is no recent data addressing the long term survival of cirrhosis patients without transplantation, but with the availability of optimal pharmacological and endoscopic therapies. We compared the long term transplant free survival of alcoholic (AC) and cryptogenic (CC) cirrhosis patients in a setting where liver transplantation was, until very recently, not available. AC and CC patient details were extracted from our database, maintained since 1995. For those who had not attended clinics within the past 4 weeks, the patient or families were contacted to obtain survival status. If deceased, cause of death was ascertained from death certificates and patient records. Survival was compared using Kaplan-Meier curves. RESULTS: Complete details were available in 549/651 (84.3%) patients (AC 306, CC 243). Mean follow up duration (SD) (months) was 29.9 (32.6). 82/96 deaths (85.4%) among AC and 80/94 deaths (85.1%) among CC were liver related. Multivariate analysis showed age at diagnosis and Child's class predicted overall survival among all groups. The median survival in Child's class B and C were 53.5 and 25.3 months respectively. Survival was similar among AC and CC. Among AC survival was improved by abstinence [HR = 0.63 (95% CI: 0.40-1.00)] and was worse with diabetes [HR=1.59 (95% CI: 1.02- 2.48)] irrespective of alcohol status. CONCLUSIONS: The overall survival of AC was similar to CC. Death in both groups were predominantly liver related, and was predicated by age at diagnosis and Child class. Among AC, presence of diabetes and non-abstinence from alcohol were independent predictors for poor survival.

Subclinical mucosal inflammation in diarrhea-predominant irritable bowel syndrome (IBS) in a tropical setting.

BACKGROUND AND AIMS: There is evidence for low-grade inflammation in the pathophysiology of post-infectious irritable bowel syndrome (IBS). We assessed the degree of subclinical intestinal mucosal inflammation in diarrhea-predominant IBS (IBS-D) in a tropical setting. MATERIAL AND METHODS: In a prospective study over 1 year, we investigated 49 patients with IBS-D (cases; median age 34 years (range 18-59); M:F 36:13), diagnosed on Rome III criteria. 14 individuals with a family history of colon cancer (median age 46.5 years (range 23-56); M:F 6:8) were selected as controls. Stools of cases and controls were tested for calprotectin. During colonoileoscopy, serial biopsies were obtained. Mucosal mast cells, neutrophils, eosinophils and lymphocytes/plasma cell infiltrate were quantified. Tissue expression of IL-8 and IL-10 was assessed in biopsies by semi-quantitative RT-PCR. RESULTS: A history suggestive of an episode of infectious diarrhea (ID) was present in 16/49 cases and 0/14 controls (p = 0.013). In cases, there were significantly more mucosal mast cells in the ileum and all segments of colon and significantly more eosinophils in the cecum. Tissue expression of IL-8 was significantly higher and IL-10 significantly lower in cases compared with controls (target/standard cDNA ratio, median (range) IL-8: 1.25 (0.75-2) vs. 0.85 (0.63-1.3), p < 0.0001, Mann-Whitney U test; IL-10: 0.33 (0-0.63) vs. 0.55 (0.5-0.7), p < 0.0001). There was a significant inverse correlation between IL-8 and IL-10 expression (Pearson correlation, (-) 0.509; p < 0.01). CONCLUSION: There was evidence of subclinical intestinal mucosal inflammation in patients with IBS-D. The finding of increased eosinophils is novel, and may be of special relevance to IBS-D in the tropics.

Osteoporosis in adult Sri Lankan inflammatory bowel disease patients.

AIM: To determine if inflammatory bowel disease (IBD) is a risk factor for osteoporosis in adult Sri Lankans. METHODS: We identified eligible subjects from among consecutive patients diagnosed with IBD who attended our outpatient clinic. We included only patients aged between 20 and 70 years. Patients who were pregnant, had significant comorbidity, or were on calcium supplements or treatment for osteoporosis within the past 6 mo, were excluded. Healthy, age- and sex-matched controls were also recruited, in a control to patient ratio of 3:1. Both groups were screened for osteoporosis using peripheral dual energy X-ray absorptiometry scanning. RESULTS: The study population consisted of 111 IBD patients (male:female = 43:68; mean age 42.5 years) and 333 controls (male:female = 129:204; mean age 43.8 years). The occurrence of osteoporosis among IBD patients (13.5%) was significantly higher than among controls (4.5%) (P = 0.001). The frequency of osteoporosis was not significantly different between ulcerative colitis (14.45%) and Crohn's disease (10.7%). However, on multivariate analysis, only age (P = 0.001), menopause (P = 0.024) and use of systemic steroids (P < 0.001) were found to be associated independently with the occurrence of osteoporosis, while IBD, severity of disease, number of relapses, duration of illness or treatment other than systemic steroids were not. CONCLUSION: IBD does not appear to be an independent risk factor for the occurrence of osteoporosis in this population. However, the use of systemic steroids was a risk factor.